Jennifer Goldman DO, MBA, FAAFP

There are good takeaways from this conversation and more to come. - Leaders must fully grasp the intricacies of risk adjustment, including its interconnections with other departments and the optimal staffing model. Stay tuned for more insights!

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Shifting the financial model alone is not sufficient for the transition - the care delivery, workforce, and many other pieces of the ecosystem with which PCPs interact also need to adjust accordingly. Funding to allow for the startup costs of transformation must be made available. A comprehensive analysis from The Commonwealth Fund: To encourage participation, practitioners say upfront payments, investment in the primary care workforce, and less emphasis on simplistic quality measures are needed, as well as more support for practices to provide accessible, comprehensive care. #primarycare #integratedcare #teambasedcare #healthcare #healthcareonlinkedin

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Here’s your recap of last week’s health IT news 🗞️ 👇 🖊️ AI Ambient Scribes • CHRISTUS Health + Abridge: The 15,000 provider Texas health system adopted the ambient scribe enterprise-wide.    • Tampa General Hospital + Nuance Communications DAX Copilot: Over 500 providers at the health system will begin utilizing the AI ambient scribe.    • Texas Oncology + DeepScribe: The statewide oncology practice adopted the AI ambient medical scribe. (ed. note: scribes continue to be hot!) ☎️ AI Contact Center • Clearstep: The AI conversational chat vendor launched a new feature allowing patients to self-schedule specialist visits. 📊 Data & Analytics • InterSystems + CLEAR: The cloud-based patient data service is integrating the identity technology to expedite access to patient records.    • WakeMed + Bamboo Health: The health system is adopting the data interoperability and encounter notification service. 🥼 Clinical Decision Support • University Hospitals + Aidoc: The Cleveland-based health system is implementing the AI clinical decision support platform across 13 of its hospitals and additional outpatient locations. 🧑‍💻 Virtual and At-Home Care • University of South Carolina School of Medicine + Rimidi: The hospital group and an affiliated multispecialty clinic are adopting the remote patient monitoring platform to reduce complications from postpartum hypertension.    • Mount Sinai Health System + HealthSnap: The medical center announced a new remote patient monitoring and chronic care management program in partnership with the virtual care management platform.    • Wheel: The telehealth company released a new AI-driven virtual care platform designed to enhance the patient experience and offer resources to help partners scale their virtual care services. 💬 Patient Engagement • CipherHealth: The patient engagement solution focused on patient rounding released a new AI summary tool.    • DexCare: The care orchestration platform completed a $75M series C funding round 🩼 Durable Medical Equipment • Better Health: The medical device and peer support network completed a $14M funding round. 🧠 Food for Thought: • Silicon Valley Bank released an interesting report on the state of investment in AI in healthcare, including stats on AI usage at healthcare organizations and the impact of leveraging AI on startup valuation. https://lnkd.in/em7AfivT    • The journal Critical Care Medicine published an editorial on an “in clinico” evaluation of a machine learning-based early warning system to predict in-hospital deterioration. We found it to be an interesting look at the actual impact of a model’s deployment on care processes and patient outcomes in a critical care setting. https://lnkd.in/eQhZbVKu

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The Psoriatic March: PsA before PsO https://buff.ly/3CQxT2s

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Key Strategic Insights = A Successful OP CDI Program The challenge of value-based care starts with a collaborative approach, when launching an Outpatient Clinical Documentation Integrity (OP CDI) program. Here are some key strategic insights to success: 1. Engage with Population Health Understand Pain Points: Begin by understanding the specific challenges faced. This fosters collaboration. Tailored Questions: Use customized questions to facilitate productive discussions and ensure alignment with needs. 2. Effective Software Implementation Manage Patient (Pt.) Volumes: Implement software solutions to efficiently handle pt. volumes. OP CDI Calculator: Utilize a calculator to determine Full-Time Equivalent (FTE) needs. Data Analytics and Reporting: Emphasize the importance of continuous improvement via data analytics. 3. Workflow Creation Establish Robust Workflows: Create strong workflows before integrating reviewers. 4. Collaboration & Communication Promote Strong Collaboration: Encourage robust communication between key stakeholders. Leverage Software: Use technology to reduce physician burnout & streamline communication. 5. Patient-Centered Approach Address social determinants of health (SDOH) & ensure accurate documentation of conditions and care plans. Patient Outcomes: Keep patient care at the center of all doc. & workflow processes. 6. Regulatory Compliance Adhere to Guidelines: Follow regulatory requirements such as CMS guidelines on Hierarchical Condition Categories (HCC) coding to avoid penalties and enhance credibility. 7. Measurable Outcomes Set Clear Goals: Aim for measurable outcomes like improved HCC recapture rates, enhanced RAF scores, better HEDIS measures, and addressing SDOH needs. 8. Stakeholder Engagement Involve All Stakeholders: Ensure that executives, clinicians, and other relevant parties are involved in planning and implementation process. Success Stories Recently, I helped several CDI directors validate their cases for OP CDI programs within Accountable Care Organizations (ACOs). By engaging with population health leadership, we identified key issues such as RAF gaps and HEDIS measures, and tailored processes to address them. For instance, a CDI director I guided successfully identified HCC and HEDIS recapture as their biggest pain points. With strategic solutions in place, they are now ready to implement the project for the 2025 budget yr., aiming to improve their HCC recapture rate by 20%, leveraging data analytics for outcomes and improvement needs. Benefits of Implementing These Strategies Align Risk Stratification: Properly align risk stratification with chronic conditions and healthcare needs. Quality Measures: Improve quality measures and address SDOH. Collaborative Team: Ensure success with a collaborative team supported by technology. Overall, these strategic actions will enhance patient care and operational efficiency. #Healthcare #Leadership #CDI #PatientCare #ValueBasedCare #HealthcareInnovation

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🔩 Q: What is a Bolt on healthcare benefit? ✅ A: Great question! Self-funded ERISA-governed plans may add on OPTIONAL services to provide more options for members and potentially save more time and money for both plans and members. We call these "bolt-on benefits" in the industry. Here are some examples, and even focused examples on #prescriptiondrugs and #pharmacy: 💊 -On site or near site clinics - that can provide quick appointments for members to get in to the doc or provider when their primary care providers are not available. At these clinics, members can obtain many drugs at these on site or near site clinics at a discount or even free to get them started and up to 100% of the drugs could be charged back to the plan. 💊 -Canadian drug importation programs - patients are allowed legally to personally import drugs with several stipulations (not biologicals, not controlled substances). I will reserve my personal opinions on these Canadian programs for now, but just know that they can be another option for members. 💊 -Cash pay on prescriptions and applying the cost to deductibles and OOPs - especially for the 1/3 of plans that are High Deductible Health Plans (HDHPs) - your plan, if you have a savvy consultant or broker, can set up a program to allow those with HDHPs to apply their receipts to their deductibles and out of pocket accumulators at the beginning of the plan year when patients have to pay out of pocket. You MUST ask your broker, however, if they can set up this option for your plan with the medical carrier, and show a clear pathway at open enrollment for members on where they may turn in their receipts to apply to their deductibles. 💉 Example: 1/1/25 is right around the corner and 70% of plans' accumulators will reset. With the Team Cuban Card, for example, people may pay cash of $748+ cash price with Yusimry, an adalimumab biosimilar, (https://lnkd.in/g5gJz_Mf) or they can purchase a more expensive option on their drug formulary. Why not take advantage of better cash pricing and rewarding the member for finding it and applying it to the deductible? 🛑 Now that the breach of fiduciary lawsuits have arrived, considering bolt on benefits is/are another critical component for plans to explore. If you offer your members options, you're demonstrating that one way your plan is meeting their fiduciary obligations. Maybe all these won't work for your plan.....but you miss 100% of the shots you never take. #pharmacybenefits #pharmacy

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For Shame: Government Removes Requirement for Hospitals To Disclose Their ICU Occupancy . Thousands can die as a result in next emergency : https://lnkd.in/ehPpKcJ9 The COVID-19 pandemic demonstrated that US hospital and health care systems were ill-prepared for the surge of patients who overwhelmed available health care resources. The lack of available ICU beds during the COVID-19 pandemic caused likely thousands of deaths that could have been preventable . Researchers estimate that thousands of early-pandemic deaths could have been avoided were it not for this shortage. However, ICU bed supply was not the root of the problem. Although, at the peak of the pandemic, there were many hospitals across the United States with ICU units that were overwhelmingly full, there were also ICUs in the same regions that were under capacity. Rather, load imbalance—a measure of the relationship of hospitals in hospital referral regions (HRRs) that are at or overcapacity while others are under capacity—was a problem. To prevent the needless loss of human life, we recommend that all hospitals disclose their load-balance plans—such as regional transfer agreements, regionally coordinated length-of-stay, and rapid conversion of hospital to ICU beds access—on a regular basis in a public forum, such as the SEC’s risk analysis, regularly disclosed in its EDGAR data site. Although health care agencies can promulgate the disclosure, the best agency for the collection of these disclosures is the Securities and Exchange Commission (SEC) due to its globally lauded expertise in both data collection and transparent dissemination. This disclosure should be mandated for hospitals through government legislation/rules. Sadly, the CDC recently lifted its requirement for hospitals to report their COVID-19 data—including the number of COVID patients being cared for in ICUs (https://lnkd.in/egcNGMaP). As we sift through the aftermath of the COVID-19 pandemic and return to a pre-COVID way of life, government agencies that bow to industry pressure with guidance changes, like this one, open us up to avoidable deaths in future pandemics. If we hope to avoid repeating the outcomes of the COVID pandemic in future health crises, legislation that mandates hospitals’ disclosure of their load-balance plans is a must. #COVID #CDC #SEC #healthcare #transparency#ICU #rural hospitals

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On October 8th, U.S. News & World Report released its annual rankings of Children's Hospitals, called "Best Children's Hospitals". It is a 174-page report describing the methodology and data tables which I scanned through. Appendix C-10 has the data on Pediatric Pulmonology which I took a deep dive into. In the attached carousel, I have recreated two datasets that matter. If I were to shop around for a hospital for my care, what really matters to me is the outcome data for a particular condition I am seeking care for and not the reputation score. However what separates the top-ranked "Best Children's Hospitals" is their reputation scores, not the outcome scores for selected conditions as in asthma here. It's a different matter whether the outcome scores used in the rankings are good measures. We will discuss them in another post. What are your thoughts? Feel free to like, share, and comment. #healthcare #hospitals #physician

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Walmart joins so many others in quickly entering and leaving or scaling back in healthcare after ambitious plans to scale. This morning, Walmart said it will close all 51 of its health-care clinics, as well as shut down their telehealth virtual care services. This is right after an announcement in March that they wanted to double the size of their clinical operations by opening up over 20 more locations this year and more next year. The reasons they cited? “Like others, the challenging reimbursement environment and escalating operating costs create a lack of profitability that make the care business unsustainable for us at this time.” As a physician, it’s been fascinating to watch over the past few years as so many non-medical companies try to get their bite of the huge percentage of the GDP that is healthcare. They pour money into trying to deliver healthcare at scale, ignoring the many concerns that hospital systems and physician private practices have been citing for years: declining reimbursements, shortages of clinicians, and expensive labor costs. Healthcare is broken, and those that are in it understand why. Patients need - and deserve - quality health care. This requires safe staffing practices, skilled clinicians who can feel good about what they do, and insurance companies that pay their bills. We can’t have a system where insurance companies can get away with record profits while finding more and more reasons not to pay for care and eroding away at the heart of healthcare. You cannot scale your way out of America’s healthcare problem. You actually need to fix the incentives, regulate insurance companies, pay clinicians appropriately, prioritize clinician well being and retention, and focus on the patient. The days of paying lip service to physicians leaving medicine and physician burnout are numbered. Supply and demand forces will necessitate real solutions that move the needle. Companies will come and go in the healthcare space when they realize how hard it is on the ground in healthcare these days. The question for patients and legislators is, who will be left to pick up the pieces if there’s no support for physicians, other healthcare workers, and hospital systems?  The percentage of clinicians leaving healthcare annually because they no longer recognize the heart of why they joined the profession is astounding, with over 1/4 of clinicians looking to leave within the next few years. Relying on the altruism of clinicians and the erosion of quality healthcare to support profits for corporations is just not a sustainable business model in healthcare - not to mention terrifying for public health. #HealthcareOnLinkedIn #PhysicianBurnout #PhysicianShortage #Walmart

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Most viewed in the last 7 days from JAMA Health Forum: This JAMA Forum discusses the current data collection mechanisms used for Medicare and proposes ways to improve nationwide data collection efforts for Medicaid. https://ja.ma/4dJuqzJ

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1. These are not healthcare companies. These are hospital management companies. 2. These health systems have jumped into the business of graduate medical education with both feet. They will groom countless medical residents into organizational chits, mindlessly ordering tests to pad the DRG rolls and case mix index, under the guise of clinical training. (Heaven help the employed physician that doesn't comply.) 3. An unspoken strategem of the for-profit systems has been to flood the market with lower acuity primary care services and drive down wages. (This is in addition to their model of deploying more autonomous APP's.) 4. It has been a long time goal of these health systems to undermine physician identity and autonomy for their own financial benefit. Imagine the kind of doctors this system will produce. 5. They've spent years corporatizing and have more access to large scale leveraged debt that physician practices don't. (One big reason why they hate private equity BTW.). Physicians must learn how to navigate this space to make our own critical investments. (Let us own and run our own hospitals and see who does a better job?) 6. Most of their local operators understand little about healthcare. In my experience, many also understand little about business. (Think "Boeing C suite" but with C and D tier business degrees.)

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📣 Wake-Up Call for Physicians! 📣 While we were immersed in our daily routines, a significant shift occurred in the healthcare landscape. Here’s a snapshot of the Producer Price Index (PPI) for hospitals and physicians from 2007 to 2024. 📊 The graph paints a clear picture: the lion’s share of the excessive healthcare expenditure 💰 was claimed by hospitals, not physicians. But that’s not the whole story. Dig a little deeper and you’ll find that a substantial portion of the hospital funds (not shown in this graph) were channeled into administrative bureaucracy. 🏥📑 We’re at a pivotal moment in healthcare. It’s time for us to take note, engage in meaningful discussions, and drive change. I’d love to hear your thoughts on this. Let’s start a conversation! 💬 Graph created from Producer Price Index (PPI) data published by US Dept of Labor #Healthcare #Physicians #Hospitals #HealthcareExpenditure #PPI

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The Association of Healthcare Value Analysis Professionals (AHVAP) celebrates Elizabeth Eisenberg, MSN, RN, CVAHP from Scripps Health for commitment to excellence in the specialty of healthcare value analysis! Liz has signified this commitment by signing the official Association of Healthcare Value Analysis Professionals (AHVAP) healthcare value analysis pledge. To learn more about the Association of Healthcare Value Analysis Professionals (AHVAP) Commitment pledge: https://lnkd.in/gqEWPBue. #AHVAP #valuebasedcare #excellenceincare #valueanalysis

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Starting April 1, 2025, Rural Health Clinics (RHCs) can include CPT Category II codes on Medicare claims. This advancement enhances quality reporting and aligns with value-based care initiatives, as these codes offer detailed insights into patient care. Previously, such submissions led to claim rejections; now, they aim to improve reporting accuracy without altering payment policies. Integrating these codes into the revenue cycle offers several benefits: 1. Accelerated Claims Processing: Detailed documentation reduces the need for additional payer audits, leading to quicker payments and less administrative burden. 2. Improved Quality Metrics: Tracking performance in areas like diabetes management aligns with programs such as Medicare’s Quality Payment Program, potentially resulting in higher reimbursements or bonuses. 3. Error Reduction: Precise coding minimizes errors in claims submissions, decreasing rework and payment delays. 4. Enhanced Negotiation Leverage: Demonstrating high-quality care through data enables better terms with private insurers, leading to higher payment rates or inclusion in premium networks. 5. Alignment with Value-Based Care: Participation in value-based contracts, where outcomes and quality metrics drive revenue, can unlock shared savings and incentive payments. While CPT Category II codes themselves are not reimbursable, their strategic use supports faster payments, fewer denials, and operational efficiency, positively impacting cash flow and the revenue cycle. #Medicare2025 #RuralHealthCare #CPTCodes #QualityReporting #HealthcareUpdates #ValueBasedCare #HealthTech #RHCUpdates #MedicalCoding #HealthPolicy #RevenueCycle #HealthcareInnovation #PatientCareQuality #HealthCareReform https://lnkd.in/etXFK3UG

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It's wild to think in 2024 we're FIRST seeing the DOJ accuse telemedicine conglomerates of criminal drug distribution. How long have we known about these practices in brick and mortar care...? Answer: decades! Take it from someone who prescribed stimulants and other psychotropics to kids over the years - painstakingly measuring and documenting the need and impact - these appalling abuses by Done and Cerebral mean we need more calls for thoughtful pause when it comes to working with startups. Particularly about funding's role - my favorite topic! 🤑 How did we end up with venture capital and PE financing in healthcare that risk the safety of kids in the name of exorbitant returns? Not that all VC or PE dollars are bad, of course, but they're certainly key drivers who shouldn't be in that seat. Did we underestimate these funders as 'barbarians at the gate', much like the pharma reps of the 90's and early 2000's heyday? Have we not learned from Purdue Pharma's aggressive and deadly Oxoycontin marketing? Purdue pleaded guilty to criminal charges and paid $600 million in fines in 2007. Or TAP Pharmaceutical Products's Lupron kickback scheme for the prostate cancer drug? TAP also pleaded guilty to criminal charges and paid $875 million in fines in 2001. Or Pfizer marketing Neurontin, an anti-seizure drug, for off-label uses, such as treating pain and bipolar disorder, even though the drug was not approved for these purposes, and paying physicians kickbacks. In 2004, Pfizer pleaded guilty to criminal charges and paid $430 million in fines. Cerebral and Done's playbooks were practically the same thing, just with a modern mid-pandemic, low-regulatory scrutiny, digital-platform twist. Will appropriate regulation ever outpace American venture greed? Is it even possible to ensure patient safety AHEAD of tragedies driven by the intersection of innovation and venture funding? If you're keeping score, healthcare regulatory reactivity: 1 million. Healthcare ounces of smartly preventive policy: 3. Blech. 😖 When will we finally own that prevention in-house? #healthcare #overdoseprevention #suicideprevention

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Don't be fooled. Value-based care won't come to you! You need to go to value-based care! How? By weaving together the principles of data, population health management, operations, finance, and change management. Yes, it's challenging, but it's worth it. If you're at the annual #FACHC conference in late July, Carrie T. and I will show you the how, and hear from Syntax Health and Austin Helton about the #VBC #contracting, #data and the impressive results we've achieved. #VBC #ValueBasedCare #valuebasedhealthcare #data #PopulationHealthManagement #pophealth #healthcarefianance #change #changemanagement

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An Outpatient Clinical Documentation Improvement (CDI) program offers substantial advantages to healthcare organizations by elevating patient care and operational efficiency. By integrating risk stratification with chronic conditions, enhancing quality measures, addressing social determinants of health, and establishing a collaborative team empowered by technology, such strategic initiatives result in improved patient outcomes and streamlined operations.

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The Illusion of Efficiency in Healthcare: A Deep Dive into ACA's Impact Remember the argument on the quality and efficiency of healthcare during the ACA debate? This argument led to policy changes in the ACA that facilitated hospitals buying up physician practices and insurance companies owning pharmacies and benefits managers—both industries becoming big in the process. The notion was that by becoming big, both industries could bring in efficiencies by eliminating wasteful expenditures. But what happened? Both industries consolidated their market share and raised prices for the consumer. Hang on, one might argue that while we could not reduce the cost, we have improved the quality, and quality comes with a price. Fair argument, right? Has the quality of care improved? Well, this paper answers that question with a resounding NO. At least in this study, the quality of healthcare—as measured by in-hospital mortality, 30-day mortality, and 30-day readmission rates among a select patient population of a large independent cardiology practice before and after their integration with a large academic health system—did not improve. Another argument used in the ACA debate was that vertical and horizontal integration would reduce the utilization of services such as labs and scans because they would be more easily accessible through electronic health records. Has this argument survived research scrutiny? Again, the answer is NO. This study found no difference in the utilization of services when comparing before and after integration. Funny enough, I asked Google AI, “Does integration of outpatient practices with hospitals improve quality?” The Google AI overview gave me this answer: “Yes, integrating outpatient practices with hospitals generally leads to improved quality of care by facilitating better coordination of patient care, streamlined communication between providers, and access to more comprehensive services across different healthcare settings, ultimately enhancing patient outcomes,” and provided a list of references. All of them were review articles by influencers saying how “it feels good.” None of them referenced how “it felt good.” I hope the L!nk€d!n algo will pass this post in its quality check. What are your thoughts? #Healthcare

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